Art3_ChinoHills_FY17_Transit_LosSerranos_Claim_CLOSEDClaimant:
Please see instructions and check list of required items below.
1.
2.
3.
4.
5.
6.
7.
City of Chino Hills
Claim Form (one-time submission)
Please submit a completed Claim Form prior to requesting reimbursement of funds. An authorizing
resolution is required with the Claim Form (see #2).
Authorizing Resolution (one-time submission)
Resolution authorizing the filing of the claim form and authorizing the submission of reimbursement
requests throughout the duration of the project. Please submit resolution with Claim Form.
Reimbursement Request Form (as needed)
This form is required for every reimbursement requested.
Back-up Documentation (required with Reimbursement Request Form)
Please attach documentation supporting the amount requested (e.g., invoices, paychecks,
purchase orders, etc.)
Certified Copy of Minute Action (completed projects only)
Certified copy of minute action authorizing the filing of the final claim and verifying project completion.
Photos of Completed Project (completed projects only)
Other (optional)
Attach any other information you wish to submit to support your claim.
Date:
Project Name:
Claimant:
Address:
Attention:
Phone No:
E-mail Address:
Amount Requested for Reimbursement:
Purpose:
( )
( X )
Authorizing Signature:
(Claimant's Chief Adminstrator or Financial Officer)
Signature
Type Name & Title
Condition of Approval:
Approval of this claim and payment by the County Auditor to this claimant are subject to monies being available and to the provision that such monies will be used only in accordance
with the approved allocation instruction.
Los Serranos Transit Access Project
City of Chino Hills
0
Please check one purpose.
Article 3 Bicycle/Pedestrian Facilities, Public Utilities Code (PUC) 99233.3
Transit Stop Access Improvements, PUC 99233.3
Grant Allocation No:
L18-CH-14
Grant Information (completed by SBCTA)
Project Name
Instructions: Please complete 1 through 4 below.
1) Article 3 Project Cost (amount being requested for reimbursement)
2) Local Match Project Cost
Total
Project Costs to Date (include amount requested above)
3) Article 3
4) Local Match
Total
Local Match Amount Remaining
Article 3 Balance Remaining
Total Amount Remaining
I certify that the information on this Financial Reporting form is true and accurate to the best of my knowledge.
The same authority that signs the Claim Form must sign this form.
Claimant:
Signed:
City of Chino Hills
Total Project Cost
187857
Amount
0
0
0
0
0
0
100757
87100
187857
Article 3 Award Amount
87100
Percent Article 3
0.463650542700032
Date:
Local Match Amount
100757
Percent Local Match
0.536349457299968